Low Income Verification Form - Curry College

CURRY COLLEGE
Student Financial Services
1071 Blue Hill Avenue
Milton, MA 02186-2395
(617) 333-2354 Fax: (617) 333-2915
Verification of Low Income
Dependent Students
Academic Year 2011-2012
A review of your financial aid application indicates your parent(s)’ total income from all sources for 2010 appears
unusually low. We need to verify how your family was supported in 2010. Your parent(s) must complete ALL of the
information requested on this form and return the document to the Office of Student Financial Services.
Section A--- Student Information
Name: _______________________________________________________ID#:____________________________
1. Did your parents receive AFDC/TANF (Welfare), SSI (Disability), or Social Security Benefits in 2010?
No
Yes --- List the name of the benefit: __________________________________
Amount per month received in 2010? $ __________________________
Number of months received in 2010? __________________________
2. Did your parent(s) live with a relative or someone else who provided them with free room and board in 2010?
No
Yes --- Name:____________________________ Relationship: ______________________________
Section B --- List of Expenses and Support for 2010
Your parent(s) must list their monthly expenses, their monthly amount of support and their source of support that they
received in the 2010 calendar year. While it may be difficult to determine some of the figures, it is necessary to provide
us with the most accurate information.
Please explain the amounts paid and the resource used to pay the following expenses. If you did not pay for these
expenses, please explain how they were paid on your behalf (relative, welfare, SSI, etc.). This form will be
considered incomplete if any section is left blank.
• Housing (rent, mortgage)
Amount paid/month: $ _________________________________________________________________________
Resource used to make payment: _________________________________________________________________
____________________________________________________________________________________________
• Utilities (heat, electricity)
Amount paid/month: $ _________________________________________________________________________
Resource used to make payment: _________________________________________________________________
____________________________________________________________________________________________
• Telephone (cellular and/or home)
Amount paid/month: $ _________________________________________________________________________
Resource used to make payment: _________________________________________________________________
____________________________________________________________________________________________

• Food
Amount paid/month: $ _________________________________________________________________________
Resource used to make payment: _________________________________________________________________
____________________________________________________________________________________________
• Transportation (car payments, insurance, repairs, public transportation)
Amount paid/month: $ _________________________________________________________________________
Resource used to make payment: _________________________________________________________________
____________________________________________________________________________________________
• Personal and miscellaneous (clothing, credit card payments, other loan payments, etc.)
Amount paid/month: $ _________________________________________________________________________
Resource used to make payment: _________________________________________________________________
____________________________________________________________________________________________
Section C --- Additional Comments (attach separate sheet if necessary)
PLEASE NOTE: If your parent(s) 2011 monthly expenses are more than their 2010 income listed on the FAFSA, they
must provide an explanation in Section C--- Additional Comments. Attach a separate sheet if necessary.
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Section D --- Signatures (both parent and student must sign)
_____________________________________
Student Signature
________________________________________
Parent(s) Signature
____________________________________
Date
_______________________________________
Date